Validation of the Bangla version of the Communication Skills Attitude Scale with the medical students of Bangladesh

Abstract Background Effective communication skill of physicians is an important component of high‐quality healthcare delivery and safe patient care. Communication is embedded in the social and cultural contexts where it takes place. An understanding of medical students' attitudes and learning communication skills would help to design and deliver culturally appropriate medical education. The Communication Skills Attitude Scale (CSAS) is a widely used and validated tool to measure the attitude of medical students toward learning communication skills in different populations, settings, and countries. However, there is no culturally adapted and validated scale in Bangla in the Bangladesh context. This study aims to culturally adapt the CSAS into Bangla, and validate it in a cohort of medical students in Bangladesh. Methods This study used a cross‐sectional survey design to collect data from purposively selected 566 undergraduate medical students from the Rajshahi division. The survey was conducted from January to December 2023. Descriptive statistics like frequency distribution and measures of central tendency were used to measure perception regarding communication skills. The sample adequacy was measured through the Kaiser–Meyer–Olkin test. The internal consistency of the items was identified using Cronbach's alpha (α) coefficients. Result The results of the study show that the Bangla version of the scale is feasible, valid, and internally consistent in the context of a developing country, Bangladesh. The overall internal consistency of the Bangla version is good since the value of Cronbach's alpha (α) is 0.882. For PAS, the internal consistency is 0.933. While, for NAS, the value is 0.719. The item‐wise average scores in the PAS indicate that female medical students are more willing to learn communication skills compared with male students (α = 0.933). While, the scores in the NAS indicate that the male students tend to have more negative attitude toward learning communication skills compared with female students (α = 0.719). Conclusion The CSAS‐Bangla is a valid and reliable tool for assessing communication skill attitudes among Bangla speaking medical students. This scale can be used in future studies to measure the attitude of students, designing and evaluating communication skills training programs in medical colleges.


| INTRODUCTION
Effective communication skill of physicians is an important component of high-quality healthcare delivery and safe patient care. 1 In a medical context, communication skills have two dimensions-social and clinical.
From a social perspective, effective communication skills of physicians facilitate building a relationship of trust and respect, [2][3][4][5][6] exchange of information and emotion about disease and illness, and empower patients in decision-making. 73][14][15][16][17][18] A physician has to communicate effectively not only with patients but with colleagues, nurses, administrators, relatives of patients and news media. 1 Because, any healthcare delivery is a team effort, effective communication with colleagues also contributes to a reduction of professional stress and burnout among healthcare professionals, [19][20][21] making fewer errors in clinical decision-making, 22,23 and health literacy of patients. 24So, a physician should have interpersonal communication skills, 25,26 and appropriate nonverbal communication skills-silence, facial expression, touch, and closer physical proximity. 27,28Improved nonverbal communication skills enhance active listening and help to develop empathy and intuition among physicians. 29A study found that medical students' caring behavior is strongly associated with their attitudes toward communication skills. 30,31Another study in South Korea found that medical students' patient-centered attitude and empathic concern are correlated with their attitude toward learning communication skills. 32This attitude is influenced by the academic curriculum of medical schools.In a 12-year-long research, Gude et al. 33 found that an emphasis on communication skills in the academic curriculum would increase positive attitudes toward learning communication skills among medical students compared with students from the traditional curriculum.
The Communication Skills Attitude Scale (CSAS) is a widely used tool to measure the attitude of medical students toward communication skills.
The scale was developed by Rees et al. 34 It has widely been used and validated in different populations, settings and countries such as Nepal, 35 the UK 36 India, 37 China 38 Malaysia, 39 Korea, 40 Iran, 41 Germany, 42 Poland, 43 and Turkey. 44There are two trends in the studies on the CSAS.Like the original CSAS, 34 some studies stick to two factorial structures, 44,45 and some studies have used a different subscale dimension. 46,47For example, Anvik et al. 48applied the CSAS differently.
They identified three factors-learning, importance, and respect-that influence medical students' attitudes toward learning communication skills.The learning factors refer to the student's feelings about the way communication skills are taught.The "importance" factors describe students' attitudes and values toward the importance of having communication skills for doctors.On the other hand, "respect" factors indicate students' feelings about whether good communication skills may help them respect patients and colleagues.
In Bangladesh, the medical education system consists of public, and private medical colleges.There are 109 medical colleges, with 37 public and 72 private medical colleges in the country.The total admission capacity of the institutions is around 14,000 students per year.To the best of our knowledge, no culturally adapted and validated scale is available in Bangla to evaluate medical students' attitudes toward learning communication skills.Against this backdrop, the objectives of this study are as follows: 1. To culturally adopt the CSAS into Bangla.
2. To validate CSAS in a cohort of medical students in Bangladesh.

| Study design and setting
This study used a cross-sectional survey design with a convenience sample of undergraduate students at medical colleges-public and private located in the Rajshahi division, northern parts of the country.The survey was conducted online from January to December 2023.Data were collected from six medical colleges-there were public and three were private.The public medical colleges include Rajshahi Medical College, Shaheed Ziaur Rahman Medical College, Pabna Medical College, and private medical colleges include Islami Bank Medical College, Rasjshai, TMSS Medical College, Bogura, Barind Medical College, Rajshahi.
Although this study selected only one division, students from all over the country enroll at the medical colleges for studying medicine.

| Participants and sampling method
Based on the objective of the study, this study used purposive sampling method to collect data from different public and private medical colleges approved by the Bangladesh Medical & Dental Council (BMDC), the state body that is responsible for establishing and maintaining quality of medical education and recognition of medical qualifications in Bangladesh.The students enrolled only undergraduate level students who were studying at Bachelor of Medicine and Bachelor of Surgery (MBBS).The study considered the following recognized sample size determination formula: Here, p = 0.5 (50%), q = 0.5 (50%), z = 1.96 (95% CI), d = 0.05 (5%), n = 384.where, p is the prevalence of outcome variables, q = 1-p, Z value = 1.96 for 95% confidence interval, α the level of significance = 5%, d the desired margin of error or precision = 0.05 (5%), n the required minimum sample size, Required minimum sample size n = 384.
However, this study reached 566 participants.The total number of students at the selected medical colleges were 4625.We aimed at reaching at least 10% of the population.However, we managed to reach 12.23% of the population for the study.

| Instrument
In this study, we used CSAS.It is a 26-item 2-factor scale with 13 items on each subscale.The factor I under Positive Attitude Scale (PAS) represented positive attitudes toward communication skills learning, and factor II under Negative Attitude Scale (NAS) represented negative attitudes.The participants were asked to rate their opinion on the statements such as "To be a good doctor, I must have good communication skills" on a scale where 1 indicated strongly disagree, 2 indicated disagree, 3 indicated neutral, 4 indicated agree, and 5 indicated strongly agree.

| ADAPTATION OF CSAS
The original CSAS was in English (see Annex-I), and it was adapted into Bangla by following standard forward and backward translation.The forward translation from English to Bangla was performed by an expert translator.The expert had a master's degree in English language and literature and had more the 15 years of experience in professional translation.He was not aware of the research.Another forward translation was performed by a medical student.He was also fluent in both English and Bangla.Later, both the forward translated versions were compared and contrasted by the paper's two authors-one was an expert in communication in healthcare, and had bachelor's and master's degrees in communication, and another was a trained physician.After addressing and accommodating differences, inconsistencies, and variances, they compiled and merged both translations into a single Bangla-translated version.Then another medical graduate and public health expert back-translated the tool into English.All the translators are native speakers of Bangla and fluent in English.The translators were instructed to use simple language and to capture the meaning of the item rather than perform a literal word-by-word translation.The backtranslation version was compiled by following similar procedures to the forward translation.Later, all four versions were evaluated by an expert committee formed for this study.The expert committee reviewed and suggested the final adaptation of the instrument (see Annex II).The reviewed version was used for the pretest among 52 respondents of the study.

| Data collection and quality assurance
First, survey questionnaire (see Annex III) was distributed among some faculty members of the selected medical colleges.The faculty members requested their students to fill up the questionnaire in different classes of the selected medical colleges.The data were stored electronically with utmost secrecy.

| Measurements and statistical methods
The data were analyzed using the statistical software Stata version 17.0.The characteristics of the study participants and their perception regarding communication skills were analyzed through descriptive statistics like frequency distribution and the measures of central tendency.The attitudinal scores for both PAS and NAS were presented with mean ± Standard Deviation.The sample adequacy was measured through the Kaiser-Meyer-Olkin test.The test statistic was marked as highly adequate if the value is more than 0.8, moderately adequate if the value is between 0.5 and 0.8, and inadequate otherwise.The internal consistency of the items was identified using Cronbach's alpha (α) coefficients.

| Reliability
We measured the reliability of the Bangla version of CSAS through internal consistency, using Cronbach's α coefficient.

| Ethical consideration
We obtained informed consent from the participants by explaining the study's aims, objectives, data collection and storage process, privacy, benefits, risks and rights to withdraw at any stage of the research.Ethical clarence for the study was obtained from the Public Health Foundation, Bangladesh (PHFBD-ERC-IP06/2023).

| Characteristics of the sample
The average age of the participants was 22 (SD = 2.6) years.More than half of the total participants were female 329 (58.1%).Around half of the total participants were from private medical colleges 299 (52.8%), and the rest were from public medical colleges.The majority of 281 (49.7%) of the participants were studying between first and second year at their medical colleges.Details are shown in Table 1.
T A B L E 1 Basic characteristics of the participants (N = 566).

| SAMPLE ADEQUACY AND INTERNAL CONSISTENCY
Overall, the KMO value is 0.940 which corresponds to excellent sample adequacy.The internal consistency of the items is good since the overall value of α is 0.882.For PAS, the internal consistency is 0.933.While, for NAS, the value is 0.719.Details are shown in Table 3.

| CORRELATION BETWEEN THE FACTORS
The items are not correlated with each other within or without the groups (p value: <0.001).Details are shown in Table 4. Table 5 shows the Eigenvalues for different factors utilized in Principal Component Analysis.Details are shown in Table 5.
Figure 2 shows the relationship between the factors used in PCA through scatter plots.As per Figure 2 and Table 5, Factor 1 is most

| DISCUSSIONS
This study translated and adapted the CSAS into the Bangla language and validated it in a cohort of medical students in Bangladesh.It found that the Bangla version of the scale is feasible, valid, and internally consistent.
The overall internal consistency of the CSAS-Bangla is 0.882, and the values of Cronbach α of the two subscales are 0.933 and 0.719.In terms of internal consistency, it has a higher degree of similarity with some previous studies.For example, the overall internal consistency of the Polish version was α 0.853, 49 and the Iranian version 0.84. 41milar to the original CSAS and some other studies that had two factorial structures, the Bangla version of the CSAS also has two components.However, several other studies in different contexts yielded more than to two subscales.For example, the Norwegian version had three subscales-"learning," "importance," and "respect" 48 ; and the Hungarian version had seven-respect and interpersonal skills, learning, the importance of communication in the medical profession, excuse, counter, exam and overconfidence, and Persian version of the CSAS had four components-important in the medical context, excuse, learning and overconfidence. 41The difference in the factorial structures may be due to socioeconomic, geographic, cultural, and linguistic differences of the participants.
To the best of our knowledge, this is the first endeavor to validate the psychometric properties of CSAS in the Bangla language, and from the context of a developing country like Bangladesh.While most of the previous validation of the scale included students from a single medical college, we collected data from various medical colleges.
The results of our study have both theoretical and practical implications.Theoretically, it will contribute to the understanding of the attitude of medical students toward learning communication skills in the context of a developing country.Moreover, it will help to improve the curriculum and delivery of medical education.Thus, it will contribute to preparing future physicians equipping them with the art and craft of communication and ensuring better healthcare delivery.
However, acknowledge that this study has some limitations.
First, we collected data from only a region of the country as the medical colleges we selected for data collection were located only in the northern region of Bangladesh.Second, we collected data mainly from undergraduate level medical students.Third, we did not put emphasis on collecting data from students of dental colleges.So, future studies be conducted in a large scale with a focus on medical and dental students from different levels and different medical colleges across the country.Future studies also should focus on postgraduate level students.

| CONCLUSION
We conclude that CSAS-Bangla is a valid and reliable tool for  Please read the following statements about communication skills learning.Indicate whether you disagree or agree with all of the statements according to the following scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree.
Scoring key: To obtain score of PAS, add scores of items

Figure 1
Figure 1 displays a steep curve in the scree plot of the Eigenvalues, indicating that the top two or three components adequately describe the data's essence.Details are shown in Figure 1.
assessing communication skill attitudes among Bangla speaking medical students in Bangladesh.The psychometric properties of this tool are a novel approach to understanding the communication dynamics of preparing future healthcare professionals in the context of a developing country, Bangladesh.This scale can be used in future studies in measuring the attitude toward learning communication skills among medical Bangladesh, designing and evaluating communication skills training programs in medical colleges in the country.AUTHOR CONTRIBUTIONS Mohammad Aminul Islam contributed to conceptualizing the study, designing the study, preparing data collection tools, data collection, data analysis, writing manuscript and finalizing the manuscript, and coordinating the project.Maskura Benzir contributed to designing the study and data collection.Md.Kaoser Bin Siddique contributed to writing the draft manuscript and data collection.Md.Abdul Awal contributed to conceptualizing the study and data collection.Mohiuddin Ahsanul Kabir Chowdhury contributed to designing the study, data analysis, and writing the manuscript.Taufique Joarder contributed to conceptualizing the study, writing and finalizing the manuscript, and supervising the project.

F I G U R E 2
Scatter plots showing the relationship between different factors of Principal Component Analysis.Scale (CSAS) 34 [Original English version] Findings from Bartlett's test for sphericity to check the correlation between the factors.Eigenvalues for the factors.